Is C4-C5 total disc replacement medically indicated for a patient with persistent neck pain and cervical radiculopathy, with MRI showing decreased size of a central disc protrusion with annular tear at C4-C5 causing moderate canal stenosis, after failed conservative treatment?

C4-C5 Total Disc Replacement is Medically Indicated for This Patient

Based on the clinical presentation, imaging findings, and failed conservative management, C4-C5 total disc replacement meets medical necessity criteria for this patient with symptomatic cervical degenerative disc disease and radiculopathy. The procedure should be performed on an ambulatory/outpatient basis, as this is the standard GLOS for cervical disc replacement per MCG guidelines.

Medical Necessity Criteria Met

The patient satisfies all key requirements for cervical disc replacement:

Neural Compression Confirmed

• Moderate canal stenosis at C4-C5 documented on MRI with central disc protrusion and annular tear effacing the thecal sac 1
• Clinical radiculopathy confirmed by positive Spurling's maneuver bilaterally, dermatomal sensory deficits (C4-C5 distribution with Grade 4 decreased sensation), and EMG showing C5 nerve root irritation 2, 3
• MRI is the gold standard for detecting nerve root compression, with 88% accuracy in predicting surgical lesions 1

Failed Conservative Management

• Patient completed extensive conservative therapy exceeding 6 weeks: trigger point injections, physical therapy 3x/week for multiple months, self-guided exercise, NSAIDs, and muscle relaxants 4, 5
• The ACR Appropriateness Criteria and clinical guidelines establish 6 weeks of conservative therapy as the threshold before surgical intervention is appropriate 1
• 75-90% of cervical radiculopathy resolves with conservative care, but this patient represents the 10-25% who require surgical intervention 1, 3

Functional Impairment

• Severe ROM restrictions: flexion and extension significantly limited, lateral flexion restricted with radicular pain reproduction 3, 6
• Persistent pain level requiring ongoing medication management
• Activities of daily living clearly impacted by persistent symptoms despite conservative treatment 2

Appropriate Imaging Grade

• Moderate canal stenosis meets the threshold for surgical intervention 1
• The insurance criteria specifically require "moderate, moderate to severe, or severe stenosis (not mild or mild to moderate)" - this patient has documented moderate stenosis
• Decreased disc height, disc desiccation, and annular tear represent structural pathology amenable to disc replacement 7

Critical Considerations

No Segmental Instability

• The case presentation does not indicate radiographic evidence of instability, which would contraindicate disc replacement 1
• Cervical spine shows straightening of lordosis but no mention of spondylolisthesis or dynamic instability

Single-Level Disease

• C4-C5 is the only symptomatic level requiring intervention, which is ideal for total disc replacement 1, 3
• FDA-approved devices are indicated for single-level cervical disc disease from C3-C7 1

Age and Activity Level

• Patient age and functional demands support disc replacement over fusion to preserve motion and potentially reduce adjacent segment degeneration 1
• Adjacent segment disease occurs in 22.2% of fusion patients at 10 years, with 3.1% incidence after disc replacement 1

Inpatient Days Certification

Zero inpatient days should be certified. Cervical disc replacement is performed as an ambulatory/outpatient procedure per MCG guidelines (GLOS: ambulatory). Modern surgical techniques, including anterior cervical approaches for single-level disc replacement, allow same-day discharge with appropriate postoperative protocols 1.

Important Caveats

Timing Consideration

• Recent evidence suggests caution with early surgical intervention in spinal cord injury without fracture-dislocation, where early decompression may worsen outcomes 1
• However, this patient has radiculopathy, not myelopathy - no upper motor neuron signs, no gait disturbance, no hyperreflexia, no Babinski sign 2
• The distinction is critical: radiculopathy with failed conservative management has favorable surgical outcomes, whereas myelopathy requires different surgical urgency considerations 2, 3

MRI Findings Correlation

• The MRI shows "decreased size" of disc protrusion, which might suggest natural resolution 1
• However, persistent moderate stenosis with annular tear and ongoing clinical symptoms despite this radiographic improvement supports intervention 3, 7
• Clinical-radiographic correlation is essential: 24-57% of asymptomatic patients have disc abnormalities on MRI, but this patient has persistent symptoms correlating with imaging 1

Alternative to Fusion

• While anterior cervical discectomy and fusion (ACDF) is the historical reference standard with 2.6% pseudoarthrosis rate, disc replacement preserves motion and may reduce adjacent segment disease 1
• The patient's clinical scenario (single-level disease, no instability, persistent radiculopathy) represents the ideal indication for disc replacement over fusion 3